Teflon granuloma of the skull base: a complication of endonasal brain surgery.
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ABSTRACT:
SUBMITTER: Soose RJ
PROVIDER: S-EPMC2039714 | biostudies-other | 2007 Jul
REPOSITORIES: biostudies-other
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Project description:Endoscopic endonasal skull base surgery (ESBS) requires high accuracy to ensure safe navigation of the critical anatomy at the anterior skull base. Current navigation systems provide approximately 2mm accuracy. This level of registration error is due in part from the indirect nature of tracking used. We propose a method to directly track the position of the endoscope using video data. Our method first reconstructs image feature points from video in 3D, and then registers the reconstructed point cloud to pre-operative data (e.g. CT/MRI). After the initial registration, the system tracks image features and maintains the 2D-3D correspondence of image features and 3D locations. These data are then used to update the current camera pose. We present registration results within 1mm, which matches the accuracy of our validation framework.
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Project description:A 70-year-old Japanese man undergoing remission induction therapy for acute monocytic leukemia (AML-M5b) developed fever and headache, and was started on antibiotics and liposomal amphotericin B (L-AMB). There was no improvement, and computed tomography and contrast-enhanced magnetic resonance imaging revealed acute rhinosinusitis and brain abscess. Successful endoscopic endonasal surgery was performed at this point, providing drainage for the rhinosinusitis and abscess. Histopathological findings showed the mucormycosis.
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Project description:BACKGROUND:Near-infrared (NIR) tumor contrast is achieved through the "second-window ICG" technique, which relies on passive accumulation of high doses of indocyanine green (ICG) in neoplasms via the enhanced permeability and retention effect. OBJECTIVE:To report early results and potential challenges associated with the application of second-window ICG technique in endonasal endoscopic, ventral skull-base surgery, and to determine potential predictors of NIR signal-to-background ratio (SBR) using endoscopic techniques. METHODS:Pituitary adenoma (n = 8), craniopharyngioma (n = 3), and chordoma (n = 4) patients received systemic infusions of ICG (5 mg/kg) approximately 24 h before surgery. Dual-channel endoscopy with visible light and NIR overlay were photodocumented and analyzed post hoc. RESULTS:All tumors (adenoma, craniopharyngioma, chordoma) demonstrated NIR positivity and fluoresced with an average SBR of 3.9 ± 0.8, 4.1 ± 1.7, and 2.1 ± 0.6, respectively. Contrast-enhanced T1 signal intensity proved to be the single best predictor of observed SBR (P = .0003). For pituitary adenomas, the sensitivity, specificity, positive predictive value, and negative predictive value of NIR-guided identification of tumor was 100%, 20%, 71%, and 100%, respectively. CONCLUSION:In this preliminary study of a small set of patients, we demonstrate that second-window ICG can provide NIR optical tumor contrast in 3 types of ventral skull-base tumors. Chordomas demonstrated the weakest NIR signal, suggesting limited utility in those patients. Both nonfunctional and functional pituitary adenomas appear to accumulate ICG, but utility for margin detection for the adenomas is limited by low specificity. Craniopharyngiomas with third ventricular extension appear to be a particularly promising target given the clean brain parenchyma background and strong SBR.
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Project description:PurposePostoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques.MethodsPubmed and Embase databases were searched for studies (2000-2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible.Results193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3-4.5%) for transsphenoidal, 9% (CI 7.2-11.3%) for expanded endonasal, and 5.3% (CI 3.4-7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity.ConclusionsModern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.
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Project description:ObjectivesTo study the effect of endoscopic endonasal transsphenoidal surgery on voice quality in patients with pituitary lesions.MethodsAn observational study comparing voice quality before and after surgery was conducted between September 2015 and September 2017 at Srinagarind Hospital, Khon Kaen University, Thailand. Pituitary tumor patients who underwent endoscopic endonasal transsphenoidal surgery were recruited. The nasal corridors were created with a type I (preserving both middle turbinates with a rescue flap) or type II (cutting one middle turbinate with a raised nasoseptal flap) for the binostril with four-hand technique. All patients were evaluated for nasal resonance, acoustic parameters, acoustic perception, and self-assessment of their satisfaction with postoperative voice changes with a visual analog scale (VAS). The patients were evaluated 1 day before surgery and at 1 and 3 months after surgery.ResultsForty-four patients, including 19 males and 25 females with a mean age of 50.0 ± 15.6 years, were enrolled. Mean scores for nasal resonance and all acoustic parameters were not significantly changed after surgery for either nasal corridor type (p > .05). Regarding acoustic perception, word and sentence and GIRBAS scores showed no significant difference before and after surgery (p > .09) in either type of nasal corridor. There was no incidence of hypernasality voice after surgery. Patients' self-satisfaction ratings (i.e., VAS) with voice quality were high and showed no significant change 1 and 3 months postsurgery (p > .05).ConclusionsThese endoscopic endonasal transsphenoidal approaches are minimally invasive skull base surgery techniques that have minimal effects on postsurgery voice quality.Trial registrationThis trial was registered at ClinicalTrial.gov (NCT02828514).Level of evidence4.
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Project description:ImportanceInjury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery does not typically occur as an isolated circumstance but often is the result of multiple factors.ObjectiveTo assess the factors associated with ICA injury in an effort to reduce its occurrence.Design, setting, and participantsThis quality improvement study used a multicenter root cause analysis of ICA injuries sustained during endoscopic endonasal skull base surgery performed at 11 tertiary care centers across 4 continents (North America, South America, Europe, and Asia) from January 1, 1993, to December 31, 2018. A fishbone model was built to facilitate the root cause analysis. Patients who underwent an expanded endoscopic endonasal approach that carried a substantial potential risk of an ICA injury were included in the analysis. A questionnaire was completed by surgeons at the centers to assess relevant human, patient, process, technique, instrument, and environmental factors associated with the injury.Main outcomes and measuresRoot cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data.ResultsTwenty-eight cases of ICA injury occurred during 7160 expanded endoscopic endonasal approach procedures (incidence of 0.4%). The mean age of the patients was 49 years, with a female to male predominance ratio of 1.8:1 (18 women to 10 men). Anatomical (23 [82%]), pathological (15 [54%]), and surgical resection (26 [93%]) factors were most frequently reported. The surgeon's mental or physical well-being was reported as inadequate in 4 cases (14%). Suboptimal imaging was reported in 6 cases (21%). The surgeon's experience level was not associated with ICA injury. The ICA injury was associated with use of powered or sharp instruments in 20 cases (71%), and use of new instruments or technology in 7 cases (25%). Two patients (7%) died in the operating room, and 3 (11%) were alive with neurological deficits. Overall, patient-related factors were the most frequently reported risk factors (in 27 of 28 cases [96%]). Factors associated with ICA injury catalyzed a list of preventive recommendations.Conclusions and relevanceThis study found that human factors were associated with intraoperative ICA injuries; however, they were usually accompanied by other deficiencies. These findings suggest that identifying risk factors is crucial for preventing such injuries. Preoperative planning and minimizing the potential for ICA injury also appear to be essential.
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Project description:Objectives Describe instrument motion during live endoscopic skull base surgery (ESBS) and evaluate kinematics within anatomic regions. Design Case series. Setting Tertiary academic center. Participants A single skull base surgeon performed six anterior skull base approaches to the pituitary. Main Outcomes and Measures Time-stamped instrument coordinates were recorded using an optical tracking system. Kinematics (i.e., mean cumulative instrument travel, velocity, acceleration, and angular velocity) was calculated by anatomic region including nasal vestibule, anterior and posterior ethmoid, sphenoid, and lateral opticocarotid recess (lOCR) regions. Results We observed mean (standard deviation, SD) velocities of 6.14 cm/s (1.55) in the nasal vestibule versus 1.65 cm/s (0.34) near the lOCR. Mean (SD) acceleration was 7,480 cm/s 2 (5790) in the vestibule versus 928 cm/s 2 (662) near the lOCR. Mean (SD) angular velocity was 17.2 degrees/s (8.31) in the vestibule and 5.37 degrees/s (1.09) near the lOCR. We observed a decreasing trend in the geometric mean velocity, acceleration, and angular velocity when approaching the pituitary ( p < 0.001). Conclusion Using a novel method for analyzing instrument motion during live ESBS, we observed a decreasing trend in kinematics with proximity to the pituitary. Additional characterization of surgical instrument motion is paramount for optimizing patient safety and training.
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Project description:Background Endoscopic endonasal surgery (EES) of the skull base often requires extensive bone work in proximity to critical neurovascular structures. Objective To demonstrate the application of an ultrasonic bone curette during EES. Methods Ten patients with skull base lesions underwent EES from September 2011 to April 2012 at the University of Pittsburgh Medical Center. Most of the bone work was done with high-speed drill and rongeurs. The ultrasonic curette was used to remove specific structures. Results All the patients were submitted to fully endoscopic endonasal procedures and had critical bony structures removed with the ultrasonic bone curette. Two patients with degenerative spine diseases underwent odontoid process removal. Five patients with clival and petroclival tumors underwent posterior clinoid removal. Two patients with anterior fossa tumors underwent crista galli removal. One patient underwent unilateral optic nerve decompression. No mechanical or heat injury resulted from the ultrasonic curette. The surrounding neurovascular structures and soft tissue were preserved in all cases. Conclusion In selected EES, the ultrasonic bone curette was successfully used to remove loose pieces of bone in narrow corridors, adjacent to neurovascular structures, and it has advantages to high-speed drills in these specific situations.
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Project description:Endoscopic endonasal skull base surgery is a promising alternative to transcranial approaches. However, standard instruments lack articulation, and thus, could benefit from robotic technologies. The aim of this study was to develop an ergonomic handle for a handheld robotic instrument intended to enhance this procedure. Two different prototypes were developed based on ergonomic guidelines within the literature. The first is a forearm-mounted handle that maps the surgeon's wrist degrees-of-freedom to that of the robotic end-effector; the second is a joystick-and-trigger handle with a rotating body that places the joystick to the position most comfortable for the surgeon. These handles were incorporated into a custom-designed surgical virtual simulator and were assessed for their performance and ergonomics when compared with a standard neurosurgical grasper. The virtual task was performed by nine novices with all three devices as part of a randomised crossover user-study. Their performance and ergonomics were evaluated both subjectively by themselves and objectively by a validated observational checklist. Both handles outperformed the standard instrument with the rotating joystick-body handle offering the most substantial improvement in terms of balance between performance and ergonomics. Thus, it is deemed the more suitable device to drive instrumentation for endoscopic endonasal skull base surgery.
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Project description:OBJECTIVE:Endoscopic endonasal approaches are increasingly performed for the surgical treatment of multiple skull
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